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Background: Previous work has demonstrated disparities in the management of cardiovascular disease among men and women. We sought to evaluate these disparities and their associations with clinical outcomes among patients admitted with acute coronary syndromes to the Veterans Affairs Healthcare System., Methods and Results: We identified all patients that were discharged with acute coronary syndromes within the Veterans Affairs Healthcare System from October 1, 2015 to September 30, 2022. Medical and procedural management of patients was subsequently assessed, stratified by sex. In doing so, we identified 76 454 unique admissions (2327 women, 3.04%), which after propensity matching created an analytic cohort composed of 6765 men (74.5%) and 2295 women (25.3%). Women admitted with acute coronary syndromes were younger with fewer cardiovascular comorbidities and a lower prevalence of preexisting prescriptions for cardiovascular medications. Women also had less coronary anatomic complexity compared with men (5 versus 8, standardized mean difference [SMD]=0.40), as calculated by the Veterans Affairs SYNTAX score. After discharge, women were significantly less likely to receive cardiology follow-up at 30 days (hazard ratio [HR], 0.858 [95% CI, 0.794-0.928]) or 1 year (HR, 0.891 [95% CI, 0.842-0.943]), or receive prescriptions for guideline-indicated cardiovascular medications. Despite this, 1-year mortality rates were lower for women compared with men (HR, 0.841 [95% CI, 0.747-0.948])., Conclusions: Women are less likely to receive appropriate cardiovascular follow-up and medication prescriptions after hospitalization for acute coronary syndromes. Despite these differences, the clinical outcomes for women remain comparable. These data suggest an opportunity to improve the posthospitalization management of cardiovascular disease regardless of sex.

Objectives: To compare 30 and 90 day real-world acute myocardial infarction (AMI) and bleeding related rehospitalization rates in acute coronary syndrome (ACS) patients receiving percutaneous coronary intervention (PCI; ACS-PCI) treated with clopidogrel or prasugrel. Research design and methods: Using the Premier hospital database, ACS-PCI patients receiving a drug-eluting (DES) or bare-metal (BMS) stent and clopidogrel or prasugrel from July 2009 to June 2011 were analyzed. Patients were included based on the prasugrel US prescribing information (USPI), excluding patients with a history of transient ischemic attack/stroke and patients ≥75 years without diabetes or prior MI. The primary endpoint was 30 day adjusted AMI rehospitalization rate. Secondary endpoints included 90 day AMI and 30 and 90 day bleeding-related rehospitalization rates. Treatment comparisons were adjusted using propensity score stratification. Results: At the index event, prasugrel patients (N = 9404) differed from clopidogrel patients (N = 74,163) by having a lower risk of comorbid conditions associated with bleeding, being more likely younger and male, having ST-elevation MI and receiving a DES. For clopidogrel and prasugrel, respectively, the observed AMI-related rehospitalization rates were 4.7% and 3.9% at 30 days (p < 0.0001) and 6.3% and 5.1% at 90 days (p < 0.0001). After adjustment, prasugrel was associated with ∼10% lower odds of AMI-related rehospitalization (30 days: OR = 0.892 [95% CI: 0.798, 0.998]; 90 days, OR = 0.901 [95% CI: 0.817, 0.994]). Adjusted bleeding-related rehospitalization rates were similar to each other (OR = 1.035 at 30 days [95% CI: 0.765, 1.399]; OR = 0.922 at 90 days [95% CI: 0.725, 1.172]).Study limitations:Treatment adherence was not assessed. Bleeding events not resulting in a hospitalization (e.g. office, outpatient, or emergency room visits), deaths outside the hospital, or readmissions to a hospital outside of the Premier alliance were not captured in the database. Conclusions: The different patient characteristics between prasugrel- and clopidogrel-treated patients suggest physicians are more selective in choosing patients for prasugrel than recommended in the prasugrel USPI. However, after adjustment for these differences, 30 and 90 day AMI rehospitalization rates were lower for prasugrel-treated patients compared to clopidogrel-treated patients, with no difference in adjusted bleeding-related rehospitalization rates. [ABSTRACT FROM AUTHOR]

Abstract: Background: Methamphetamine use is an increasing problem in the United States. Despite the similarities to cocaine in clinical presentation, methamphetamine effects on the cardiovascular system are not as clearly understood. Objectives: The purpose of this retrospective review is to evaluate the cardiovascular outcomes of methamphetamine exposures reported to both the California Poison Control System (CPCS) and two Level 1 trauma centers. Methods: CPCS records from 2000−2009, as well as inpatient and emergency department charts from two Level 1 trauma centers during the time frame of 2000−2004 were reviewed. Charts of adults with coded methamphetamine exposures were included. Results: Records of 2356 adults with methamphetamine exposure were assigned levels of severity according to National Poison Data System Medical Outcomes Criteria. Out of the combined charts reviewed from the CPCS data and hospital registries, 584 cases were coded as minor effects, 450 as moderate effects, 208 as major effects, and 28 as deaths. Of the included 1270 cases, 627 electrocardiograms (ECGs) were analyzed. Together, troponins and ECGs showed evidence of myocardial ischemia in 82 total cases, which is 6.5% of the cases reviewed. Cocaine was a co-ingestant in 10 of the 82 cases. Conclusions: This study presents a large cohort of methamphetamine users. The study found that chest pain and myocardial ischemia were reported in a number of cases. Although no true incidence can be taken from this dataset, it provides a large-scale review of methamphetamine use and its possible association with acute coronary syndromes. [Copyright &y& Elsevier]

The article discusses the impact of new medical trainees in the process of care and outcomes of patients with acute cardiovascular conditions. It says that the U.S. healthcare system incorporates thousands of inexperienced physicians in various positions. Meanwhile, studies shows that July annual admission and mortality rates of the patients are not associated.

Coronary heart disease is the primary health risk for all Americans. Acute coronary syndromes (ACS) is the term used to denote any 1 of 3 clinical manifestations of coronary heart disease: unstable angina, non-5T elevation myocardial infarction, and ST-elevation Ml. The major challenge to healthcare providers is the rapid and accurate identification of patients with ACS who would benefit from immediate thrombolysis or percutaneous coronary interventions. The purpose of this article is to describe the incidence, causes, risk factors, assessment, and diagnosis of patients presenting with ACS as well as current recommendations for nurses who treat patients with ACS. [ABSTRACT FROM AUTHOR]

Comments on the push for regional treatment centers for patients with acute coronary syndromes. Planning for regionalized care begun by the State of Maryland; Presentation of concerns for this approach to patient care and possible unintended consequences; Arguments for the benefits of the ACS centers, which are based on studies with notable limitations; Lack of clear consensus on the specific nature of ACS regionalization; Risks to patients; Concerns about how the direct admission of ACS patients will be handled; Economic implications; Concern that regionalization may be the end of quality care at non-ACS facilities; Conclusion and belief there is not enough data to support the value of these centers at this time.

Percutaneous coronary interventional (PCI) procedures are commonly performed in the United States. The process of caring for this patient population has changed dramatically over the last 10 years, with many of the changes being driven by an evolution in the knowledge base underlying nursing practice. The purpose of this article is to provide a summary and critique of nurse-sensitive outcomes related to patients undergoing PCI procedures and to identify gaps in the literature to provide recommendations for future research. Nursing research on indicators related to costs of care, morbidity, symptom management, functional status, patient/family knowledge, patient responses, behavior, and home/occupational function following PCI are discussed in this review. [ABSTRACT FROM AUTHOR]

Coronary heart disease is the number 1 killer of adults in the United States, affecting 1 in 5 men and women. However, women are more likely than men to die after an acute coronary event and are less likely to receive prompt or aggressive treatment. Few studies have examined the role of emergency nurses' triage decisions in these disparities, even though nurses often determine initial patient priority and urgency status for emergency cardiac evaluation and treatment. The purpose of this prospective study was to examine if nurses' initial triage decisions could predict admission or discharge diagnoses for acute coronary syndromes (ACS). A total of 108 nurses' triage decisions made by 13 nurses were examined. There were no differences in nurses' triage decisions based on patient gender, race, or age. By multivariate analysis, chest pain, history of coronary heart disease, history of myocardial infarction, and smoking were predictive of an ACS decision. Overall, accuracy for predicting admission diagnosis was poor. Sensitivity and specificity were 57% and 59%, respectively, with a positive predictive value of 68% and a negative predictive value of 56%. It was similarly poor for predicting discharge diagnosis. Sensitivity and specificity for discharge diagnosis were 55% and 69%, respectively, with a positive predictive value of 17% and a negative predictive value of 93%. Findings indicate limitations in the ability of nurses' triage decisions to predict admission and discharge diagnoses for ACS. [ABSTRACT FROM AUTHOR]

Unstable angina is in most cases caused by partial or complete coronary artery occlusion due to the disruption of an atherosclerotic plaque and to thrombus formation. An immediate antithrombotic approach is essential to prevent fatal and non-fatal myocardial infarction, and the combination of aspirin and unfractionated heparin has played a pivotal role in the past years. Low molecular weight heparins have improved pharmacokinetic and pharmaco-dynamic properties over unfractionated heparin that have resulted in greater efficacy and safety in the field of venous thromboembolism. Low molecular weight heparins can be administered by once or twice daily subcutaneous injections at fixed, weight-adjusted doses without the need for monitoring. Because of their potential, many recent clinical trials have evaluated their efficacy and safety in the management of patients with unstable angina. Three low molecular weight heparins have so far been tested: nadroparin, dalteparin and enoxaparin. The results of the published trials confirm that the newer compounds are at least as safe and effective as unfractionated heparin, and offer considerable therapeutic advantages. Nevertheless, the different properties of the three compounds and perhaps the different designs of the clinical trials have led to not entirely comparable findings. [ABSTRACT FROM AUTHOR]

Background Influenza virus infection most commonly causes acute respiratory tract illness, however may also lead to non-respiratory complications including acute cardiovascular (CV) events. We describe the frequency of and risk factors for acute CV events in adults hospitalized with influenza in the United States. Methods We included adults aged > 18 years hospitalized during influenza seasons 2010–2011 through 2017–2018 in FluSurv-NET, a multi-state population-based surveillance system that includes detailed medical chart review of patients hospitalized with laboratory-confirmed influenza. We defined acute CV events by International Classification of Diseases (ICD) primary and secondary discharge diagnosis codes for acute heart failure (aHF), acute ischemic heart disease (aIHD), hypertensive crisis, cardiogenic shock, acute myocarditis, acute pericarditis and cardiac tamponade. We calculated the frequency of acute CV events and used multivariable logistic regression among the 87% treated with influenza antivirals to identify independent factors associated with aHF and aIHD, the two most common diagnoses. Results Of 80,374 adults hospitalized with laboratory-confirmed influenza, 12% had > 1 acute CV event. We found that aHF (46%) and aIHD (42%) were the most common, followed by hypertensive crisis (8%), cardiogenic shock (3%), acute myocarditis (0.7%), acute pericarditis (0.4%) and cardiac tamponade (0.2%). Compared with treated patients without an acute cardiovascular event, treated patients with aHF (Figure A) and aIHD (Figure B) were more likely to be older, currently/formerly use tobacco and have underlying conditions including cardiovascular disease, diabetes mellitus, and kidney disease. Conclusion Among adults hospitalized with laboratory-confirmed influenza, acute CV events are common, particularly among those with prior cardiovascular disease. During the influenza season, clinicians should consider influenza virus infection in hospitalized adults who present with acute CV events. Non-respiratory complications, specifically aHF and aIHD, may be an under-recognized contributor to the burden of influenza. Disclosures All authors: No reported disclosures. [ABSTRACT FROM AUTHOR]

Several key reports from the American Heart Association meeting, held in Orlando (FL, USA) in November 2011, are presented related to anti-thrombotic therapy in acute coronary syndrome and the use of dronedarone in permanent atrial fibrillation is discussed in this brief (and selective) overview of this meeting. A summary of the ATLAS-TIMI-51, TRACER and PALLAS trials is provided. [ABSTRACT FROM AUTHOR]

Percutaneous coronary intervention (PCI) improves anginal chest pain in most, but not all, treated patients. PCI is associated with unplanned readmission for angina and non-specific chest pain within 30-days of index PCI. Patients with an index hospitalization for PCI between January-November in each of the years 2010-2014 were included from the United States Nationwide Readmissions Database. Of 2 723 455 included patients, the 30-day unplanned readmission rate was 7.2% (n = 196 581, 42.3% female). This included 9.8% (n = 19 183) with angina and 11.1% (n = 21 714) with non-specific chest pain. The unplanned readmission group were younger (62.2 vs 65.1 years; P < 0.001), more likely to be females (41.0% vs 34.2%; P < 0.001), from the lowest quartile of household income (32.9% vs 31.2%; P < 0.001), have higher prevalence of cardiovascular risk factors or have index PCI performed for non-acute coronary syndromes (ACS) (OR:3.46, 95%CI 3.39-3.54). Factors associated with angina readmissions included female sex (OR:1.28, 95%CI 1.25-1.32), history of ischemic heart disease (IHD) (OR:3.28, 95%CI 2.95-3.66), coronary artery bypass grafts (OR:1.79, 95%CI 1.72-2.86), anaemia (OR:1.16, 95%CI 1.11-1.21), hypertension (OR:1.13, 95%CI 1.09, 1.17), and dyslipidemia (OR:1.10, 95%CI 1.06-1.14). Non-specific chest pain compared with angina readmissions were younger (mean difference 1.25 years, 95% CI 0.99, 1.50), more likely to be females (RR:1.13, 95%CI 1.10, 1.15) and have undergone PCI for non-ACS (RR:2.17, 95%CI 2.13, 2.21). Indications for PCI other than ACS have a greater likelihood of readmission with angina or non-specific chest pain at 30-days. Readmissions are more common in patients with modifiable risk factors, previous history of IHD and anaemia., (© 2021 The Authors. Clinical Cardiology published by Wiley Periodicals LLC.)

Background: Nationally representative studies have shown significant racial and socioeconomic disparities in the triage and diagnostic evaluation of patients presenting to the emergency department (ED) with chest pain. However, these studies were conducted over a decade ago and have not been updated amidst growing awareness of healthcare disparities., Objective: We aimed to reevaluate the effect of race and insurance type on triage acuity and diagnostic testing to assess if these disparities persist., Methods: We identified ED visits for adults presenting with chest pain in the 2009-2015 National Hospital Ambulatory Health Care Surveys. Using weighted logistic regression, we examined associations between race and payment type with triage acuity and likelihood of ordering electrocardiography (ECG) or cardiac enzymes., Results: A total of 10,441 patients met inclusion criteria, corresponding to an estimated 51.4 million patients nationwide. When compared with white patients, black patients presenting with chest pain were less likely to have an ECG ordered (adjusted odds ratio [OR] = 0.82, 95% confidence interval [CI] = 0.69-0.99). Patients with Medicare, Medicaid, and no insurance were also less likely to have an ECG ordered compared to patients with private insurance (Medicare: OR = 0.79, CI = 0.63-0.99; Medicaid: OR = 0.67, CI = 0.53-0.84; no insurance: OR = 0.68, CI = 0.55-0.84). Those with Medicare and Medicaid were less likely to be triaged emergently (Medicare: OR = 0.84, CI = 0.71-0.99; Medicaid: OR = 0.76, CI = 0.64-0.91) and those with Medicare were less likely to have cardiac enzymes ordered (OR = 0.84, CI = 0.72-0.98)., Conclusions: Persistent racial and insurance disparities exist in the evaluation of chest pain in the ED. Compared to earlier studies, disparities in triage acuity and cardiac enzymes appear to have diminished, but disparities in ECG ordering have not. Given current Class I recommendations for ECGs on all patients presenting with chest pain emergently, our findings highlight the need for improvement in this area., Competing Interests: Declaration of Competing Interest The authors declared that there is no Conflict of Interest., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background Mental health after spontaneous coronary artery dissection (SCAD), a cause of myocardial infarction in young women, remains largely unexplored. We assessed the prevalence and severity of psychiatric symptoms after SCAD. Methods and Results Individuals with confirmed SCAD who consented to the Mayo Clinic "Virtual" Multicenter SCAD Registry were sent the Posttraumatic Stress Disorder Diagnostic Scale for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition , Patient Health Questionnaire-9, Generalized Anxiety Disorder-7, Anxiety Sensitivity Index, Connor-Davidson Resilience Scale, 36-Item Short-Form Health Survey, and an SCAD-specific questionnaire. Among 782 patients contacted, 512 surveys were returned. Most respondents were women (97.5%), with median age at time of SCAD and survey completion of 47 and 52 years, respectively. Eighty-two percent had at least one trauma, with mild or more posttraumatic stress disorder symptoms in 28%. Symptoms of anxiety and depression were observed in 41% and 32%, respectively. On multivariable analysis, those of younger age at first SCAD and low resiliency scored higher on measures of trauma, anxiety, and depression. Those with higher anxiety sensitivity had more severe anxiety and posttraumatic stress disorder symptoms. Emotional and social quality of life was higher in those with high resiliency scores. Time from SCAD event to survey completion was associated with lower Generalized Anxiety Disorder-7 score severity. Conclusions Survivors of SCAD have significant rates of posttraumatic stress disorder, depression, and anxiety, which are associated with lower quality of life specifically among those with lower resiliency. Given the prevalence and potential impact, screening and treatment for the psychological distress is advised. Behavioral interventions targeted toward resiliency training may be beneficial for this patient population.

Background: Diagnosis and grading of diastolic dysfunction (DD) is challenging, with different studies using heterogeneous criteria and guidelines not routinely applied in clinical practice. Our aim was to apply the 2016 American Society of Echocardiography/European Association of Cardiovascular Imaging classification of DD among a contemporary population of patients with acute coronary syndromes (ACS) by analyzing its correlation with N-terminal pro b-type natriuretic peptide (NT-proBNP) and impact on clinical outcomes., Methods: Independent investigators blinded to each other and to the clinical history reviewed digitally stored images to apply 2016 and 2009 DD definitions to 380 patients (mean age 66 ± 13 years, 75% men) with ACS admitted to the coronary care unit between January 2016 and March 2018., Results: DD was frequent with both definitions, yet the concordance was weak (kappa =0.21, p < 0.01). Inter-observer reliability was greater by applying the 2016 algorithm (kappa = 0.89, p < 0.001). There was a significant correlation between NT-proBNP and worsening DD (Spearman's rho r = 0.54 for 2016 and r = 0.24 for 2009 algorithms, both p < 0.001). Worse DD was associated with worse clinical presentation and increased risk of events (HR for the cumulative incidence of heart failure and death during follow-up 2.15 [95% CI 1.66-2.78, p < 0.001] and 1.82 [95% CI 1.39-2.40, p < 0.001] for 2016 and 2009 classifications, respectively, all p < 0.001)., Conclusions: The agreement between 2016 and 2009 DD definitions was poor, with newer guidelines having grater interobserver reliability. The positive graded association between 2016 DD classification and NT-proBNP and its association with clinical outcomes provide a validation of the latest guideline algorithm in ACS patients., Competing Interests: Declaration of competing interest The authors have no conflicts of interest to disclose., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Objective: Current guidelines recommend that patients with non-ST elevation acute coronary syndromes (NSTEACS) receive dual antiplatelet therapy (DAPT) early in hospitalisations. However, observational studies suggest that this rarely occurs. We evaluated site-specific variation and clinical outcomes associated with early DAPT among patients undergoing angiography for NSTEACS., Methods: In this observational analysis, we identified patients undergoing angiography for NSTEACS in Veterans Affairs hospitals from 2008 to 2016 and assessed characteristics and site variation associated with early DAPT (administration <24 hours of admission). Using propensity matching, we compared time to revascularisation, recurrent myocardial infarction (MI) and mortality between those receiving early DAPT and those not receiving early DAPT (administration ≥24 hours)., Results: Of 45 569 patients undergoing angiography for NSTEACS, 15 084 (33%) received early DAPT. Early DAPT was more frequent in patients with non-ST elevation MI, prior surgical revascularisation and among patients undergoing revascularisation. There was a greater than twofold difference in early DAPT across sites, independent of patient characteristics (median OR 2.43, 95% CI 2.28 to 2.55). There was no difference in time topercutaneous coronary intervention (PCI) between groups, but a significant delay to surgical revascularisation with early DAPT (median 4 vs 3 days, p<0.001) without reduction in hazard of death or MI (HR 1.08, 95% CI 1.00 to 1.16) and similar results demonstrated in the subgroup of patients undergoing revascularisation (HR 1.02, 95% CI 0.91 to 1.13)., Conclusion: Among NSTEACS patients undergoing coronary angiography, early DAPT was not associated with improvement of outcomes but was associated with delays in surgical revascularisation., Competing Interests: Competing interests: SWW received research support to the Denver Research Institute from Abiomed, Cardiovascular Systems Incorporated and Merck Pharmaceuticals. The other authors have no industry relations to disclose., (© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Dual-antiplatelet therapy is recommended for all patients with acute coronary syndromes (ACS), regardless of performance of revascularization. Ticagrelor (T) was shown to be superior to clopidogrel (C) in a large, randomized clinical trial, but data from real-world practice are lacking. We identified ACS patients from our institutional registry who underwent percutaneous coronary intervention and received one of the two drugs at hospital discharge based on physician preference. Among 1439 patients, there were 774 patients (53.8%) in the C group and 665 patients (46.2%) in the T group. T and C patients were similar except for a higher incidence of ST-elevation myocardial infarction (MI) and lower frequency of prior MI in the T group (P<.05 for both). The primary endpoint - 1-year all-cause death - occurred in 58 C patients and 48 T patients (6.9% vs 7.9%, respectively; P=.42). Sixty percent of these deaths (n = 62; 31 C and 31 T) were considered cardiovascular in nature based on chart review. By multivariable logistic regression model, only dialysis (hazard ratio [HR], 2.64; 95% confidence interval [CI], 1.50-4.64; P=.01), age (HR, 1.83; 95% CI, 1.49-2.24 per 10 years; P<.001), and prior heart failure (HR, 1.78; 95% CI, 1.12-2.82; P=.02) were independent predictors of 1-year death. Treatment with T was not a predictor of death (HR, 1.21; 95% CI, 0.81-1.82; P=.35) or cardiovascular death (HR, 1.18; 95% CI, 0.72-1.94; P=.52). Landmark analysis from day 10 showed similar results (HR, 1.13; 95% CI, 0.71-1.84; P=.59). Thus, we conclude that C and T have similar rates of 1-year all-cause mortality, which is predominantly affected by age, end-stage renal disease, and pre-existing heart failure.

Introduction: Cardiovascular disease accounts for 800,000 deaths in the United States. Although it is stablished that acute heart failure complicating myocardial infarction increases mortality, there is limited data regarding the incidence of heart failure(HF) according to the affected ventricular wall and if there is a difference on the outcomes Hypothesis: Acute heart failure is mostly encountered in anterior wall myocardial infarction Methods: 2014 Nationwide Inpatient Sample (NIS) analysis was performed. Patients with a primary diagnosis of STEMI were included and categorized into general STEMI, anterior wall MI(AWMI), inferior wall MI(IWMI),anterolateral wall MI(ALWMI), inferolateral wall MI(ILWMI),lateral wall MI(LWMI) and inferoposterior MI (IPWMI). Secondary diagnosis of acute HF was generated. Primary outcome was in-hospital mortality. Secondary outcomes were cost of stay,mechanical ventilation, cardiogenic shock ,acute kidney injury requiring dialysis(AKID), cardiac arrest, non invasive ventilation(NIV),mechanical circulatory support(MCS)(Impella and intraortic ballon pump) ,and hemorrhage requiring transfusion(HRT). Statistical analysis was done using STATA IC 15. Results: 138,765 patients with STEMI were identified. 37,045 presented with HF. 43 % (16,155) had AWMI, 30% (11,110) IWMI, 11%(3980) ALWMI, 5% (1865) ILWMI,3% (1280) LWMI, 3% (1149) IPWMI. Aged ranged from 65-68 years, 30-40% were females. STEMI patients with HF had increased mortality(OR 1.29 p<0.001), cardiogenic shock(OR 2.1 p<0.001), mechanical ventilation (OR 2.5 p<0.001), AKID (OR 1.9 p<0.001),NIV utilization(OR 4.9 p<0.001) as well MCS use(OR 3.16p<0.001), HRT(OR 1.52 p<0.001), and cardiac arrest(OR 1.67 p<0.001). Although higher incidence of HF was seen in AWMI, LWMI had the highest odds of death (OR 2.42 p=0.002) and cardiogenic shock(OR 4.19 p=0.002). Highest odds of cardiac arrest was seen in the IWMI (OR 2.29 p<0.001) and LWMI (OR 2.13 p=0.001) groups. IWMI(OR 3.5 p<0.001) and IFPWMI(OR 3.6 p<0.001) were associated with highest odds of MCS utilization. Increased odds of AKID was seen in AWMI (OR 2.3 p<0.001)and IWMI(3.0 p<0.001). Odds of mechanical ventilation and NIV utilization were increased in all STEMI subgroups. Length of stay was increased in all subgroups Conclusions: HF complicating STEMI is associated with increased mortality, NIV utilization, mechanical ventilation, HRT as well as MCS utilization. HF had higher incidence in anterior wall MI but lateral wall MI was associated with highest mortality. [ABSTRACT FROM AUTHOR]

Introduction: Rural communities in the United States experience significant barriers to quality healthcare, resulting in higher incidence of disease and lower life expectancy. One potential source for such disparity may include variations in the medical care following acute myocardial infarctions (AMI), which affect approximately 1,500,000 people in the United States each year. This study sought to determine if the geographic area where Medicare patients were hospitalized following AMI predicts quality of care and short-term outcomes. Methods: Hospital-level data was quarried from the 2014 Centers for Medicare & Medicaid Services report on 'Readmissions Complications and Deaths' and 'Timely and Effective Care'. Hospitals were classified based on their geographic county, using the National Center for Health Statistics Rural-Urban Continuum Codes (RUCC), from RUCC-1 (most-urban) to RUCC-6 (most-rural). Hospital-level metrics of quality care and risk-adjusted outcomes were analyzed using Kruskal-Wallis H test and stratified by RUCC classification. Results: A total of 4,734 hospitals were identified, with 17.8% residing in RUCC-1 counties, 15.4% in RUCC-2, 16.8% in RUCC-3, 11.0% in RUCC-4, 16.4% in RUCC-5, and 22.5% in RUCC-6. There was significantly higher risk-adjusted 30-day mortality (χ2 = 95.059, p < 0.001) and rehospitalization (χ2 = 73.762, p < 0.001) among more rurally classified hospitals. Additionally, there was significantly lower measures of quality care among more rurally classified hospitals: statin at discharge (p < 0.001), aspirin prescribed at discharge (p = 0.004), primary PCI received within 90 minutes of hospital arrival (p = 0.008), aspirin at arrival (p < 0.001), and median time to ECG (p = 0.011). Linear regression analysis of the quality care metrics revealed only increased statin use at discharge was correlated with improved 30-day mortality (R2 = 0.064, p = 0.004). Conclusions: In the Medicare population, substantial variations exist between rural and urban hospitals in both the treatment and outcomes of AMI. Although existing metrics of quality care only partially correlated with short-term outcomes, identification and implementation of new strategies to improve timely and effective care are necessary to alleviate cardiovascular healthcare disparities in rural communities. [ABSTRACT FROM AUTHOR]

Introduction: Previous studies on anomalous coronary artery suggested its association with significant stenosis and worse in-hospital outcomes. Limited information is available about the prevalence of anomalous coronary artery and utilization of Percutaneous coronary intervention(PCI) in this population. Methods: We derived our study cohort from HCUP's Nationwide Inpatient Sample (NIS) database (2004-2014). Anomalous coronary artery and PCI related hospitalizations were recognized using ICD-9-CM diagnostic code 746.85 and procedural code 36.06,36.07 and 00.66 respectively in either primary or secondary fields, Cochran-Armitage trend test was used to generate p-value. Results: We identified 59,819 patients with anomalous coronary artery in our study cohort (83.6% age ≥50 years, 69.5% male, 65.2% white), exhibiting significant increase from 4,187 in 2004 to 5940 in 2014 (relative increase of 45.3 %). Utilization of PCI in this population has increased from 14% in 2004 to 17.3 % in 2014 (ptrend <.0001). The most common comorbid conditions coexisting with PCI admissions were dyslipidemia (68.5%), Hypertension (66%), Coronary artery disease (54.2%) and Smoking (41.3%), STEMI (27.3%); All exhibit increasing prevalence from 2004-2014 (ptrend <.0001). (Fig 1B). Weekend admission has increased from 16.2 % to 23% (ptrend <.0001) and maximum PCI (40.6%) were performed in the southern region of United States. Conclusions: Prevalence of anomalous coronary artery has significantly increased in united states with a concomitant increase in PCI utilization in this population. We also noted a concurrent increase in the prevalence of comorbidities such as smoking, dyslipidemia, coronary artery disease, hypertension, STEMI and weekend admission over the study period in these patients. [ABSTRACT FROM AUTHOR]

Introduction: It is estimated that in the United States, each year, >780,000 persons will experience an acute coronary syndrome (ACS). Approximately 70% of these will have non ST elevation-myocardial infarction (NSTEMI). Optimal timing of angiography in NSTEMI is matter of debate. Hypothesis: The aim of this retrospective analysis was to evaluate the 1 year major cardiovascular events (MACE) in patients presenting with NSTEMI and undergoing percutaneous intervention (PCI) Methods: Within our PCI database we identified 1550 patients who underwent PCI for NSTEMI. We then divided the population into 3 groups based on door to balloon time (D2BT) (group 1= D2BT<90 min; group 2 = D2BT >90 min <24h; group 3 = D2BT >24 h). Primary outcome was MACE/target vessel revascularization (TVR) (composite of MI, death and TVR) at 1 year Results: Characteristics of the patient population is reported in the table. Patients with D2BT<90 min were more likely to present with cardiogenic shock and had higher baseline and peak troponin level, indicating a significant bias related to the operator choice. In-hospital, 6 months and 1 year outcomes are reported in the figure. Overall the group with D2BT>90 min and <24h had better outcomes. Conclusions: In this large cohort of patients presenting with NSTEMI, patients undergoing PCI between 90 min to 24 h from presentation had better 1 year outcomes. However, treatment selection bias makes causal inference concerning rapid revascularization and outcome unreliable. Randomized clinical trials are warranted to assess outcome of rapid revascularization in patients presenting with NSTEMI [ABSTRACT FROM AUTHOR]

Introduction: Frailty is an independent predictor of all-cause and cardiac mortality, non-fatal myocardial infarction, and major bleeding after acute myocardial infarction (AMI) admission. The objective of this study was to estimate the prevalence of frailty among adults age 75 years or older during AMI admission and examine the relationship between frailty status and receipt of interventions. Methods: We used the Premier healthcare database to identify encounters for older adults with primary diagnoses of AMI (ICD-9: 410-414, 429.2; ICD 10: I20-I25). We classified individuals as frail or not using the validated Claims-based Frailty Index (CFI) algorithm, which generated a frailty score for each patient using 21 variables derived from inpatient and outpatient data from 6 months prior to the index AMI admission. We described patients' characteristics and receipt of PCI stratified by frailty status. Results: From 2000 to 2016, we identified 501,581 encounters for patients >=75 years admitted with AMI. The median [IQR] age was 82 [77, 88] years, 52% were women, 75% were Caucasian, and 4% were of Hispanic ethnicity. The prevalence of frailty was 18%. Frail patients were older, more likely to be women and ethnic minority members, and have more comorbidities. Frail patients were much less likely to receive PCI than non-frail (15% vs 34%, p <0.001) and much less likely to receive CABG (frail 1% vs non-frail 9%, p <0.001). The utilization of PCI as a treatment of AMI is significantly higher in non-frail vs. frail patients at all ages, but even usage in non-frail patients decreases significantly in patients over 85 years of age (Figure). Conclusions: In the United States, frailty is common among older patients during index AMI hospitalization and the risk increases with age. From public health perspective, research efforts should focus on the evaluation of clinical outcomes for older adults after cardiovascular interventions based on their frailty status to learn whether exclusion of frail patients from interventions is appropriate or not. [ABSTRACT FROM AUTHOR]

Objective: To examine racial differences in outcomes with coronary computed tomographic angiography (CCTA) vs standard emergency department (ED) evaluation for chest pain., Design: Retrospective analysis of the prospective, randomized, multicenter Rule Out Myocardial Ischemia/Infarction by Computer Assisted Tomography (ROMICAT-II) trial., Setting: ED at nine hospitals in the United States., Participants: 940 patients who were Caucasian or African American (AA) presenting to the ED with chest pain., Interventions: CCTA or standard ED evaluation., Main Outcome Measures: Length of stay, hospital admission, direct ED discharge, downstream testing and repeat ED visit or hospitalization for recurrent chest pain at 28 days. Safety end points: missed acute coronary syndrome (ACS) and cumulative radiation exposure during the index visit and follow-up period., Results: 659 (66%) patients self-identified as Caucasian and 281 (28%) self-identified as AA. AA were younger and more often female compared with Caucasians, had a higher prevalence of hypertension (64% vs 49%, P<.001) and diabetes (23% vs 14%, P<.001) and a lower prevalence of hyperlipidemia (28% vs 51%, P<.001). ACS was more frequent among Caucasians (10% vs 2%, P<.001). Randomization to CCTA resulted in a reduction in median LOS for Caucasians (7.4 vs 24.7 hours, P<.001) and AA (8.9 vs. 26.3, P<.001; P-interaction=.88). Both AA and Caucasian patients experienced greater radiation exposure and more downstream testing with CCTA compared with standard evaluation., Conclusions: Early CCTA reduced median LOS for both AA and Caucasian patients presenting to the ED with chest pain by approximately 17 hours compared with standard evaluation., Competing Interests: Competing Interests: None declared.

Presents a reply to a letter to the editor of "The Journal of the American Medical Association" regarding acute coronary syndromes and regionalization of care. Discussion of an article by Rathore and colleagues found in a previous issue of the journal.

Background: Most studies of sex and race differences after acute myocardial infarction (AMI) have not taken into account differences in life expectancy in the general population. Years of potential life lost (YPLL) is a metric that takes into account the burden of disease and can be compared by sex and race., Objectives: This study sought to determine sex and race differences in long-term survival after AMI using life expectancy and YPLL to account for differences in population-based life expectancy., Methods: Using data from the Cooperative Cardiovascular Project, a prospective cohort study of Medicare beneficiaries hospitalized for AMI between 1994 and 1995 (N = 146,743), we calculated life expectancy and YPLL using Cox proportional hazards regression with extrapolation using exponential models., Results: Of the 146,743 patients with AMI, 48.1% were women and 6.4% were black; the average age was 75.9 years. Post-AMI life expectancy estimates were similar for men and women of the same race but lower for black patients than white patients. On average, women lost 10.5% (SE 0.3%) more of their expected life than men, and black patients lost 6.2% (SE 0.6%) more of their expected life than white patients. After adjustment, women still lost an average of 7.8% (0.3%) more of their expected life than men, but black race became associated with a survival advantage, suggesting that racial differences in YPLL were largely explained by differences in clinical presentation and treatment between black and white patients., Conclusions: Women and black patients lost more years of life after AMI, on average, than men and white patients, an effect that was not explained in women by clinical or treatment differences., (Copyright © 2015 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: Cardiogenic shock (CS) is associated with significant morbidity, and mortality rates approach 40% to 60%. Treatment for CS requires an aggressive, sophisticated, complex, goal-oriented, therapeutic regimen focused on early revascularization and adjunctive supportive therapies, suggesting that hospitals with greater CS volume may provide better care. The association between CS hospital volume and inpatient mortality for CS is unclear., Methods and Results: We used the Nationwide Inpatient Sample to examine 533 179 weighted patient discharges from 2675 hospitals with CS from 2004 to 2011 and divided them into quartiles of mean annual hospital CS case volume. The primary outcome was in-hospital mortality. Multivariate adjustments were performed to account for severity of illness, relevant comorbidities, hospital characteristics, and differences in treatment. Compared with the highest volume quartile, the adjusted odds ratio for inpatient mortality for persons admitted to hospitals in the lowest-volume quartile (≤27 weighted cases per year) was 1.27 (95% CI 1.15 to 1.40), whereas for admission to hospitals in the low-volume and medium-volume quartiles, the odds ratios were 1.20 (95% CI 1.08 to 1.32) and 1.12 (95% CI 1.01 to 1.24), respectively. Similarly, improved survival was observed across quartiles, with an adjusted inpatient mortality incidence of 41.97% (95% CI 40.87 to 43.08) for hospitals with the lowest volume of CS cases and a drop to 37.01% (95% CI 35.11 to 38.96) for hospitals with the highest volume of CS cases. Analysis of treatments offered between hospital quartiles revealed that the centers with volumes in the highest quartile demonstrated significantly higher numbers of patients undergoing coronary artery bypass grafting, percutaneous coronary intervention, or intra-aortic balloon pump counterpulsation. A similar relationship was demonstrated with the use of mechanical circulatory support (ventricular assist devices and extracorporeal membrane oxygenation), for which there was significantly higher use in the higher volume quartiles., Conclusions: We demonstrated an association between lower CS case volume and higher mortality. There is more frequent use of both standard supportive and revascularization techniques at the higher volume centers. Future directions may include examining whether early stabilization and transfer improve outcomes of patients with CS who are admitted to lower volume centers., (© 2015 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.)